Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH
Aalborg University, Aalborg, Denmark.
J Am Heart Assoc. 2018 May 27;7(11):e009592. doi: 10.1161/JAHA.118.009592.
Longer QRS duration (QRSd) improves, but increased left ventricular (LV) end-diastolic volume (LVEDV) reduces, efficacy of cardiac resynchronization therapy (CRT). QRSd/LVEDV ratios differ between sexes. We hypothesized that in the EchoCRT (Echocardiography Guided Cardiac Resynchronization Therapy) trial enrolling patients with heart failure with QRSd <130 ms, those with larger LVEDV would deteriorate but those with the highest QRSd/LVEDV would with CRT.
Primary outcome in patients (n=787, 72% men, 93% New York Heart Association class III, QRSd <130 ms, LV ejection fraction ≤35%, LV dilation and dyssynchrony) randomized to CRT-ON or CRT-OFF and followed up for 19 months was compared according to LVEDV (height indexed) or QRSd/LVEDV ratio, in multivariable analysis. Structural remodeling was assessed echocardiographically 6 months after implantation. Patients with baseline LVEDV higher than or equal to median worsened with CRT (death/heart failure hospitalization: CRT-ON versus CRT-OFF, 35.2% versus 24.5% [hazard ratio, 1.64; 95% confidence interval, 1.11-2.42; =0.012]), but those with LVEDV lower than median remained unaffected. Patients with the highest QRSd/LVEDV ratio improved with CRT (death/heart failure hospitalization in top quartile: 20.9% in CRT-ON [n=91] versus 28.3% in CRT-OFF [n=106] [hazard ratio, 0.64; 95% confidence interval, 0.34-1.24; =0.188], versus the remaining quartiles: 31.7% in CRT-ON [n=300] versus 24.8% in CRT-OFF [n=290] [hazard ratio, 1.47; 95% confidence interval, 1.07-2.02; =0.016], test for interaction =0.046). QRSd and dyssynchrony were similar between groups. The 3-way test for interaction indicated no sex-specific effects. However, numerically, men with LVEDV higher than or equal to median accounted for worse outcomes of CRT-ON. Women, with the highest QRSd/LVEDV ratio exhibited significant reverse remodeling.
CRT has opposite effects among patients with heart failure with QRSd <130 ms according to LV size: worsening outcomes in patients with larger LV, but inducing beneficial effects in those with smaller LV.
URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00683696.
QRS 波时限（QRSd）延长可改善，但左心室（LV）末期容积（LVEDV）增加会降低心脏再同步化治疗（CRT）的疗效。男女之间的 QRSd/LVEDV 比值存在差异。我们假设在 EchoCRT（超声心动图指导的心脏再同步化治疗）试验中，纳入 QRSd<130ms 的心力衰竭患者，LVEDV 较大的患者会恶化，但 QRSd/LVEDV 最高的患者会受益于 CRT。
在这项纳入 787 名患者（72%为男性，93%为纽约心脏协会（NYHA）III 级，QRSd<130ms，LV 射血分数≤35%，LV 扩张和不同步）的随机 CRT-ON 或 CRT-OFF 临床试验中，根据 LVEDV（高度指数）或 QRSd/LVEDV 比值进行多变量分析，比较了主要终点（19 个月时的死亡率/心力衰竭住院率）。在植入后 6 个月时通过超声心动图评估结构重构。基线时 LVEDV 高于或等于中位数的患者 CRT 后恶化（死亡率/心力衰竭住院率：CRT-ON 与 CRT-OFF，35.2%与 24.5%[危险比，1.64；95%置信区间，1.11-2.42；=0.012]），而 LVEDV 低于中位数的患者则不受影响。QRSd/LVEDV 比值最高的患者受益于 CRT（死亡率/心力衰竭住院率最高四分位数：CRT-ON 为 20.9%[n=91]，CRT-OFF 为 28.3%[n=106][危险比，0.64；95%置信区间，0.34-1.24；=0.188]，而其余四分位数为：CRT-ON 为 31.7%[n=300]，CRT-OFF 为 24.8%[n=290][危险比，1.47；95%置信区间，1.07-2.02；=0.016]，交互检验=0.046）。组间 QRSd 和不同步性相似。3 路交互检验未显示出性别特异性影响。然而，数值上，LVEDV 高于或等于中位数的男性 CRT-ON 后结局较差。女性中，QRSd/LVEDV 比值最高的患者出现明显的逆向重构。
对于 QRSd<130ms 的心力衰竭患者，根据 LV 大小，CRT 具有相反的效果：LV 较大的患者结局恶化，但 LV 较小的患者则有获益。
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